journal of prosthodontic research 62 (2018) 273–280

Contents lists available at ScienceDirect

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Review

Cervical margin relocation in indirect adhesive restorations: A

literature review
Jelena Juloskia,b,* , Serhat Kökena , Marco Ferraria,c
a
Department of Medical Biotechnologies, University of Siena, Siena, Italy
b
Clinic for Pediatric and Preventive Dentistry, University of Belgrade, Belgrade, Serbia
c
Department of Restorative Dentistry, School of Dentistry, University of Leeds, Leeds, UK

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: The aim of this review was to summarize the existing scientific literature investigating on
Received 29 July 2017 cervical margin relocation technique (CMR) performed prior to the adhesive cementation of the indirect
Received in revised form 29 September 2017 restorations.
Accepted 29 September 2017
Study selection: An electronic search with no date restriction was conducted in the MEDLINE database,
Available online 15 November 2017
accessed through PubMed. The following main keywords were used: “cervical margin relocation”, “coronal
margin relocation”, “deep margin elevation” and “proximal box elevation”.
Keywords:
Results: Seven in vitro studies and 5 clinical reports investigating on CMR are taken into consideration for
Cervical margin relocation
Proximal box elevation
the present review. The most frequently investigated parameter in almost all of the in vitro studies was
Deep margin elevation the marginal adaptation of the indirect restorations. One study additionally assessed the influence of
Indirect adhesive restorations CMR on the fracture behavior of the restored teeth and one study assessed the bond strength of the
Review indirect composite restoration to the proximal box floor. Clinical reports provided documentation with a
detailed description of the treatment protocol. In the current literature no randomized controlled clinical
trials or prospective or retrospective clinical studies on CMR technique could be found.
Conclusions: On the basis of the reviewed literature, it can be concluded that currently there is no strong
scientific evidence that could either support or discourage the use of CMR technique prior to restoration
of deep subgingival defects with indirect adhesive restorations. Randomized controlled clinical trials are
necessary to provide the reliable evidence on the influence of CMR technique on the clinical performance,
especially on the longevity of the restorations and the periodontal health.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

1. Introduction considered necessary in order to avoid detrimental effects on

Restoring large posterior defects with proximal caries extending
below the cemento-enamel junction (CEJ) and cavity margins
located beneath the gingival tissues represents a very common
clinical situation. Due to advances in adhesive technology, develop-
ment of modern materials and increasing aesthetic requests, a
treatment plan in such cases often includes indirect adhesive
restoration [1,2]. Unfortunately, when restoring cavities with deep
cervical margins two major clinical problems may occur: problems of
biological nature and technical-operative problems [3].
The biological problems refer to the possible violation of the
“biological width”, a recommended distance of 3 mm or more
between the restorative margins and the alveolar crest that is
* Corresponding author at: Department of Medical Biotechnologies, Policlinico Le
Scotte, Viale Bracci 16, Siena 53100, Italy.
E-mail address: juloski@unisi.it (J. Juloski).
neighboring soft and hard periodontal tissues [4]. If the principle of
biologic width is not respected, it is suggested to obtain the
necessary space in one of two ways: surgically, by surgical crown
lengthening [5] or orthodontically, by tooth extrusion [6].
The technical-operative problems start with difficulties in tooth
preparation in subgingival areas and are followed with a series of
challenges in the impression taking, the adhesive cementation of
the restoration and the successive phases of finishing and polishing
of the margins [7]. Most of the above mentioned issues are related
to inferior insight and access to the deep parts of the cavity and
impossible or inadequate isolation of the operating field with a
rubber dam, which leads to inappropriate moisture control and
blood and/or saliva contamination throughout the clinical
procedures [8].
To make the clinical procedures simpler and less fault-prone,
Dietschi and Spreafico in 1998 introduced a technique named
“cervical margin relocation” (CMR) [9]. In 2012 Magne and Spreafico

https://doi.org/10.1016/j.jpor.2017.09.005
1883-1958/© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
274 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280
referred to the same technique as “deep margin elevation” (DME)
[10]. Similar names, such as “coronal margin relocation” and
“proximal box elevation”, could also be heard among the practi-
tioners and found in the literature. This technique proposes
application of composite resin in the deepest parts of the proximal
areas in order to reposition the cervical margin supragingivally,
which is supposed to facilitate the isolation and improve impression
taking and adhesive cementation of indirect restorations [9,10]. The
CMR technique could be considered, to a certain extent, as a non-
invasive alternative to a surgical crown lengthening.
The problem of extensive subgingival defects that still remains,
regardless of the technique applied, is limited or no enamel present
at deep cervical margins, leaving only dentin and cementum as the
main substrates for adhesion. Adhesive bonding to the etched
enamel is proved to be efficient and stable [11]. Adhesion to dentin,
on the other hand, depends on numerous factors related to the
substrate morphology [12], on the type of the adhesive [13] and on
the sensitive application technique [14]. Therefore, adhesive
bonding to deep cervical dentin and maintaining the margins of
the adhesive restoration sealed throughout the time could not be
considered entirely predictable and safe.
Whether the CMR technique is the most optimal treatment
option for the restoration of deep cavities reaching below CEJ, how
the proposed advantages and possible disadvantages could affect
the clinical performance of the indirect restorations and which are
the most appropriate materials and techniques that should be
applied in such situations are the topics extensively discussed
among clinicians. Nevertheless, not much scientific support could
be found in the currently available literature. Therefore, the aim of
this review was to summarize the existing scientific knowledge on
CMR technique performed prior to the adhesive cementation of the
indirect restorations.
2. Study selection
2.1. Search strategy
For the identification of the studies to be included in this
review, an electronic search with no date restriction was
conducted in the MEDLINE database, accessed through PubMed.
The following main keywords were used: “cervical margin
relocation”; “coronal margin relocation”; “deep margin elevation”
and “proximal box elevation”. A further manual search was
performed as well; checking for eligible papers in the bibliogra-
phies of the initially retrieved articles and exploring the websites
of the relevant journals.
2.2. Inclusion criteria
The present review sought only for articles where composite
resin materials were used as materials for relocation of the cervical
margin. Only articles considering indirect adhesive restoration, as a
type of final restoration, were included. Because no randomized
controlled clinical trials (RCTs) existed in this field, descriptive
studies that made reference to the CMR clinical procedure were
also included. The search was limited to the articles published in
English language.
2.3. Exclusion criteria
Publications focusing on relocation of the cervical margin using
glass ionomer cements were not included in the present review.
Studies that used teeth without a restoration or teeth restored with
a direct composite restoration with subgingival cervical margin
were also excluded. Articles in any language other than English
were left out.
The search and the selection process carried out by two review
authors independently finished on 1st June 2017. After the
screening of the titles and the abstracts, full texts of all reviewed
articles were obtained and carefully read. Upon the discussion
between the authors, on the basis of the reported inclusion and
exclusion criteria, 7 in vitro studies, 1 review article with a case
report and 4 articles describing the CMR technique were selected
for the present literature review.
3. Results
The results of the reviewed studies were categorized and
presented in two main parts: (1) review of in vitro studies and (2)
review of clinical reports.
3.1. Review of in vitro studies
In the current scientific literature 7 in vitro studies investigating
on CMR are taken into consideration for the present review
[15–21]. The most frequently investigated parameter in almost all
of the studies was the marginal adaptation of the indirect
restorations [15–19,21]. Only one study additionally assessed the
influence of CMR on the fracture behavior of the restored teeth [18]
and one study assessed the bond strength of the indirect composite
restoration to the proximal box floor [20]. The overview of the
main characteristics, the materials employed and the designs of
the reviewed studies are reported in Table 1.
3.1.1. Marginal adaptation
All 6 studies that evaluated the influence of CMR on the
marginal quality of the adhesively luted restorations performed
the analysis using the scanning electron microscopy (SEM),
observing the margins on gold-sputtered epoxy resin replicas of
the teeth at 50 [19] and 200 magnification [15–18,21]. The
marginal integrity was calculated in the same way, as the
percentage of continuous margin in relation to the individual
assessable margin, following the well-established protocol consis-
tent with previous studies [22]. The quality of the marginal
adaptation was assessed before and after thermo-mechanical
loading (TML) [15–19,21]. However, the adhesive interfaces that
were observed and analyzed were not always the same in all of the
studies.
Most of the studies supported the fact that no differences
existed in marginal quality of the restorations placed directly on
dentin, following the conventional luting procedure, or on
composite restorations used for relocation of the cervical margin
[15,17–19,21]. One study recorded that, only after being subjected
to TML, conventional technique showed superior marginal
adaptation compared to CMR technique [16]. Moreover, in most
of the studies TML was found to significantly deteriorate the
integration at enamel and dentin margins [15–17] and at onlay/
luting composite interface [18]. But it was also recorded that TML
did not result in inferior marginal quality, regardless of the
materials tested [19,21].
With regard to the materials employed for CMR, one study
investigated on the performance of flowable and conventional
restorative composite materials when used for CMR [19]. No
significant differences in the marginal integrity were found
between traditional or flowable composite, before or after TML,
for either ceramic or composite CAD/CAM crown [19]. The
potential use of self-adhesive resin cements as material for
CMR, although deviant from their original indication spectrum, has
been explored due to their easy clinical manipulation that could be
appealing for dental practitioners [15,16]. Based on the discourag-
ing results obtained and significantly inferior quality of the
marginal adaptation to dentin, they were not recommended for
 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280 275

this indication in clinical practice, although differences were
noticeable among various self-adhesive cements [15,16].
Moreover, in order to evaluate whether polymerization
shrinkage of composite material used for CMR could affect the
quality of the margins, 3 investigations were performed applying
one or more layers of composite on the cervical margin of the
proximal boxes [15–17]. Two 1.5-mm increments of a fine hybrid
composite (Tetric A2; Ivocalr Vivadent, Schaan, Liechtenstein)
applied for CMR did not perform any better then did one 3-mm
increment, in terms of marginal adaptation of the final restoration
[17]. On the contrary, results of another two studies [15,16] showed
that marginal integration to dentin of a restorative composite
(Clearfil Majesty Posterior; Kuraray, Noritake Dental Inc., Tokyo,
Japan) is improved when composite is layered in three consecutive
1-mm increments than in one 3-mm increment for CMR. Although
initially no difference existed among group without CMR and
groups where composite was layered in one or three increments,
after TML significant degradation of the interface was noticed and
statistically significant differences emerged among the groups
[15,16]. In particular, bonding directly to dentin without CMR was
found to be comparable to CMR composite layered in 3 increments
but significantly better than CMR applied only in one layer [15]. In a
subsequent study of the same group of authors [16], the results
were slightly different. Conventional luting technique directly to
dentin performed significantly better even than dentin covered
with 3 layers of composite, which was also significantly better than
CMR applied only in one layer. Therefore, the authors concluded
that, although conventional luting procedure is considered as the
most effective over time, the CMR technique could be accepted a
valid procedure and application of composite in more layers
achieved better performance in terms of marginal quality to dentin
compared to a single layer application [15,16].

Table 1
Overview of the in vitro studies.

Author/ Groups (study design)
reference
Marginal adaptation
Roggendorf 5 groups: (1) and (2) CMR
et al. [15] with self-adhesive cements
(3) CMR in 1 layer; (4) CMR in
3 layers; (5) without CMR.
Frankenberger 6 groups: (1), (2) and (3) CMR
et al. [16] with self-adhesive cements
(4) CMR in 1 layer; (5) CMR in
3 layers; (6) without CMR.
Zaruba et al. 4 groups: (1) margin in
[17] enamel; (2) margin in dentin,
CMR in 1 layer; (3) margin in
dentin, CMR in 2 layers; (4)
margin in dentin, without
CMR.
Spreafico et al. 4 groups: 2 groups based on
[19] restorative material used for
CMR and 2 subgroups based
on material used for
fabrication of the crowns.
Müller et al. 3 groups: based on material
[21] used for luting the inlays
CMR adhesive/composite material Number of
CMR
composite
layers
2 self-adhesive resin cements: (1)
Maxcem Elite (Kerr), (2) G-Cem
(GC Corp.); (3) and (4) self-etch
adhesive AdheSe (Ivoclar,
Vivadent) + Clearfil Majesty
Posterior (Kuraray)
3 self-adhesive resin cement: (1)
Maxcem Elite (Kerr), (2) G-Cem
(GC Corp.), (3) RelyX Unicem (3M
ESPE); (4) and (5) self-etch
adhesive AdheSe (Ivoclar,
Vivadent) + Clearfil Majesty
Posterior (Kuraray)
Total-etch adhesive Syntac Primer,
Syntac Adhesive, Heliobond
(Ivoclar Vivadent) + fine hybrid
composite Tetric A2 (Ivoclar
Vivadent)
(1) 3-step total-etch adhesive
Optibond FL (Kerr) + Filtek Flow
Supreme XTE (3M ESPE); (2) 3-
step total-etch adhesive Optibond
FL (Kerr) + Filtek Supreme XTE
(3M ESPE)
Scotchbond Universal Adhesive
(3M ESPE) in total-etch
mode + Filtek Supreme XTE (3M
ESPE)
Luting agent of final restoration Type of final indirect restoration
1 layer Total-etch adhesive Syntac Primer, Laboratory made composite
(3 mm); Syntac Adhesive, Heliobond MOD inlay Clearfil Majesty
3 layers (Ivoclar Vivadent) + resin cement Posterior (Kuraray)
(3  1 mm) Variolink II (Ivoclar Vivadent)
1 layer Total-etch adhesive Syntac Primer, CAD/CAM-fabricated MOD
(3 mm); Syntac Adhesive, Heliobond inlay: leucite-reinfirced glass-
2 layers (Ivoclar Vivadent) + resin cement ceramic IPS Empress CAD
(2  1.5 mm) Variolink II (Ivoclar Vivadent) (Ivoclar Vivadent)
1 layer Total-etch adhesive Syntac Primer, CAD/CAM-fabricated MOD-
(3 mm); Syntac Adhesive, Heliobond inlay: feldspatic ceramic
2 layers (Ivoclar Vivadent) + fine hybrid (Vitablocs Mark II, Vita)
(2  1.5 mm) composite Tetric A2 (Ivoclar
Vivadent)
2 layers Total-etch adhesive Optibond FL CAD/CAM-fabricated crowns:
(2  1 mm) (Kerr) + RelyX Ultimate (3M ESPE) (1) resin composite with
nanoceramic fillers (Lava
Ultimate, 3M ESPE); (2) lithium
disilicate (IPS e.max CAD,
Ivoclar Vivadent)
Not (1) Scotchbond Universal CAD/CAM-fabricated MOD-
specified Adhesive (3M ESPE) in total-etch inlay: resin composite with
(layers of mode + RelyX Ultimate (3M ESPE); nanoceramic fillers (Lava
2 mm) (2) total etch adhesive Syntac Ultimate, 3M ESPE)
Primer, Syntac Adhesive,
Heliobond + Variolink II (Ivoclar
Vivadent); (3) self-adhesive resin
cement Panavia SA Cement
(Kuraray)

Marginal adaptation and fracture behaviour

Ilgenstein et al. 4 groups: 2 groups based on
[18] presence or absence of CMR
and 2 subgroups based on
material used for fabrication
of the onlays.
3-step total-etch adhesive
Optibond FL (Kerr) + Tetric
EvoCeram (Ivoclar Vivadent)
2 layers Scotchbond Universal Adhesive CAD/CAM-fabricated MOD-
(2  1 mm) (3M ESPE) in total-etch onlay: (1) feldspatic ceramic
mode + RelyX Ultimate (3M ESPE) (Vitablocs Mark II, Vita): (2)
resin composite with
nanoceramic fillers (Lava
Ultimate, 3M ESPE)

Microtensile bond strength

Da Silva 4 groups: 2 groups based on
Gonçalves presence or absence of CMR
et al. [20] and 2 groups based on resin
cement used for luting the
inlays.
Total-etch adhesive system Adper 2 layers (1) total-etch adhesive system Indirect laboratory made
Scotchbond 1 XT (3M (2  1 mm) Adper Scotchbond 1 XT (3M composite inlay (Gradia
ESPE) + Filtek Z250 (3M ESPE) ESPE) + Relyx AEC; (2) self- Indirect; GC Corp.)
adhesive resin cement G-Cem (GC
Corp.)
276 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280
The influence of CMR on the marginal integrity of indirect
restorations made of different materials was the issue investigated
and discussed in two studies [18,19]. In both studies the
restorations were prepared by CAD/CAM technology. One study
tested onlays milled of feldspathic ceramic (VITABLOCS Mark II,
Vita Zahnfabrik, Bad Säckingen, Germany) and composite resin
blocks with nanoceramic fillers (LAVA Ultimate; 3M ESPE, St. Paul,
MN, USA) [18], while another study used the same composite
blocks (LAVA Ultimate) to fabricate crowns and compared their
behavior to crowns made of lithium disilicate (IPS e.max, Ivoclar
Vivadent, Schaan, Liechtenstein) [19]. These two studies reported,
to a certain extent, conflicting results. While Spreafico et al. [19]
found no significant differences in marginal integrity between
margins with and without CMR for both types of crowns, before or
after TML, Ilgenstein et al. [18] revealed that composite inlays
exhibited overall better marginal integrity compared to ceramic
inlays. In particular, at the tooth/composite interface after TML,
composite inlays luted directly to dentin measured significantly
higher percentage of continuous margins than any other group. In
addition, comparing only the groups with CMR at the onlay/luting
composite interface, before and after TML, a significant reduction
in marginal quality was detected in specimens restored with
ceramic onlays, while degradation of the margin was not observed
for teeth restored with composite onlays. It should be mentioned
that the restorative material LAVA Ultimate CAD/CAM used for
fabrication of crowns [19], the manufacturer no longer indicates
for crowns. The material continues to be indicated only for
restorations with an internal retentive design element (such as
inlays and onlays) and veneer restorations. This is to be considered
when interpreting the results of the studies investigating on
crowns made of this material.
The study by Müller et al. focused on the material for luting the
inlays, when bonded directly to dentin of deep proximal cavities
and when bonded to restorative composite material used for CMR
[21]. No difference was observed in terms of marginal integrity for
luting the inlays directly to dentine or composite used for CMR.
Also, no significant reduction of integrity was found after TML and
all investigated materials showed promising results for luting the
indirect restorations. Therefore, this study suggests that there is no
difference in bonding the inlay to dentine or composite used for
CMR. However, the critical interface between the dentin below CEJ
and CMR composite was the matter of interest of this study.
3.1.2. Fracture behavior
The study by Ilgenstein et al. [18] additionally investigated the
impact of CMR and material of CAD/CAM onlays on the fracture
behavior of endodontically treated molars. After TML the teeth
were subjected to load until failure in order to determine the
resistance to fracture and the fracture pattern. The lowest mean
fracture value was recorded for group without CMR and feldspathic
ceramic onlay and the highest mean value for group without CMR
and composite resin onlay. Between these two values there were
the two groups that have undergone cervical margin relocation,
which both revealed similar fracture resistance regardless of the
material used for the onlay restoration. The only statistically
significant difference in load to fracture was noticed between two
groups without CMR. Additionally, the study demonstrated that
ceramic restorations tend to have less severe fractures that do not
involve tooth itself, whereas composite restorations transfer more
stress to tooth structure causing catastrophic fractures below the
bone level.
3.1.3. Bond strength
One study aimed to evaluate the influence of CMR on the
microtensile bond strength (MTBS) of composite inlays to the
proximal box floor [20]. The groups with proximal cervical margin
located in dentin 1 mm below the CEJ were compared with those
where cervical margins were relocated 1 mm above CEJ using a
restorative composite (Filtek Z250; 3M ESPE) applied in two 1-mm
thick increments. Further aim of this study was to compare the
bond strength of inlays luted with two different cements: resin
cement used with total-etch adhesive (RelyX ARC used in
combination with Adper Scotchbond 1XT; 3M ESPE) and self-
adhesive resin cement (G-Cem; GC Corp., Tokyo, Japan).
The results showed that MTBS values increased when the
proximal cavity floor was elevated with a composite. However, this
difference in bond strength was statistically significant only when
self-adhesive resin cement was used for the cementation of the
inlay. When resin cement with a total-etch adhesive was used for
luting there was no significant difference between the groups with
and without CMR. According to the authors, the main reason for
such a result could be the good interaction between the resin
composite used for CMR and the self-adhesive resin cement. When
two luting cements were compared within the same location of the
cervical margin, no significant differences in bond strength were
recorded, regardless of their different mechanism of adhesion to
dentin. However, one should also take into consideration that the
failures during MTBS testing happened at the different interfaces.
In both groups with CMR the most frequent mode of failure was
adhesive failure between dentin and composite used for CMR,
which supports the fact that good bonding is achieved between
resin cement and CMR composite, as well as the fact that bonding
to cervical dentin still remains challenging and unpredictable [11].
Also, noticeable difference in failure modes was reported in groups
without CMR. While 60 % of specimens cemented with self-
adhesive resin cement failed adhesively between dentin and resin
cement, the same percentage of specimens luted with a total-etch
adhesive and a resin cement showed mixed adhesive failures.
3.2. Review of clinical reports
In the current literature no randomized controlled clinical trials
or prospective or retrospective clinical studies on CMR technique
could be found. One review article that specifically concentrated on
this topic and that reported a clinical case was identified [23]. One
article presented the principles of the technique [10]. In addition,
several review articles on indirect adhesive restorations in
posterior areas looked back also on the CMR technique
[3,24,25]. These articles provided clinical documentation with a
detailed description of the treatment protocol. The protocols
suggested and described in the above mentioned articles became
the matter of this part of the present review (Table 2).
3.2.1. CMR material
With regard to the most appropriate adhesive system and
composite material employed for the supragingival relocation of
the cervical margin, various recommendations were found in the
current literature. Most of the reviewed articles consider a
traditional 3-step total-etch adhesive as the preferred adhesive
system [10,23,25], such as OptiBond FL (Primer and Adhesive, Kerr
Corp., Orange, CA, USA) [10] or Syntac (Primer, Adhesive and
Heliobond, Ivoclar Vivadent, Lichtenstein) [23]. In order to avoid
over-etching of dentin in the subgingival area where enamel is
usually very thin, if any is present, Rocca et al. suggest
simultaneous etching of thin interproximal enamel in this area
together with dentin only for 5–10 s, or, as an alternative, 2-step
self-etch adhesive systems can be used without performing
selective enamel etching [25].
Furthermore, both flowable as well as traditional viscous
restorative composites could be selected for CMR technique,
according to the mentioned studies. Specifically, in a case
presented by Kielbassa and Philipp, a base of flowable composite
 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280 277

(Gaenial Universal Flo, GC Corp.) was applied, followed by small
portions of filled viscous composite resin (Gaenial, GC Corp.) [23].
On the other hand, flowable composite in 1–1.5-mm thickness was
proposed by Veneziani [3] and up to 2 mm thickness of the
flowable or traditional restorative composite, in 1 or 2 increments,
was suggested by Magne and Spreafico [10]. Besides, it was also
noted that, if microhybrid or nanohybrid restoratives are to be
used, they should be preheated, to facilitate placement and
minimize the risk of interlayer gaps [10]. Moreover, two articles
specify that highly filled flowable composites (e.g, Premise Flow;
Kerr Corp.) or bulk fill flowables (e.g, SureFil SDR Flow; Dentsply
Pty. Ltd., Victoria, Australia) are highly recommended for CMR, due
to its consistency and ease of use [24,25]. Flowables should,
however, not be used in thick layers, and their thickness should be
limited to 1–1.5 mm [24,25]. As the margin should be relocated to
at least 0.5 mm over the free gingival margin [25], if more material
is needed, a combination of flowable and traditional restorative
composite is proposed [24]. The light curing of the final composite
increment should be protected by a thick layer of glycerin gel
[10,25], as to eliminate the superficial oxygen inhibition layer,
which can interfere with the setting of some impression materials
[26].
3.2.2. Application technique
According to Veneziani, three different clinical situations can
be identified, based on technical-operating and biological
parameters [3]. Only in Grade 1, when rubber dam can be
correctly placed in the sulcus sufficiently to show the cervical
margin, the coronal relocation of the margin could be carried out.
In the other two clinical situations, surgical exposition of the

Table 2
Overview of the clinical reports.

Author/ CMR CMR composite Thickness, Rubber Matrix and Finishing of Treatment Luting agent of Type of final Follow-up
reference adhesive material number of CMR dam wedge CMR prior to final restoration indirect period
composite isolation application composite bonding of restoration
layers final
restoration
Veneziani Not Flowable Flowable Yes Circumferential Not specified Not Not specified Composite Not
[3] specified composite composite 1 to stainless steel specified onlays applicable
1.5 mm thick matrix and
wooden wedge
Magne and 3-step Flowable or 2 mm thickness Yes Modified curved Elimination Cleaning Not specified Indirect Two cases
Spreafico total-etch traditional of the CMR Tofflemire of excess with ceramic at 9 and
[10] adhesive restorative composite (1 or matrix, matrix with no.12 airborne- onlay 12 years
(eg, materials; 2 increments) height reduced to blade or a particle follow-up
OptiBond microhybrid or 2 to 3 mm; if sickle scaler abrasion
FL; Kerr) nanohybrid necessary
restoratives matrix-in-a-
should be matrix
preheated technique;
wedging is
typically not
possible
Kielbassa 3-step Flowable Not reported No Circumferential Bucket- Application 3-step total- CAD-CAM- 3 months
and total-etch composite stainless steel shaped of a primer etch adhesive fabricated
Philipp adhesive (Gaenial matrix fixed in diamond (GC Corp.) Syntac Primer, ceramic inlay
[23] Syntac Universal Flo, Tofflemire burs, flexible Syntac (IPS Empress
Primer, GC Corp.), retainer and discs and Adhesive, CAD, Ivoclar
Syntac followed by wooden wedge polishing Heliobond Vivadent)
Adhesive, small portions strips (Ivoclar
Heliobond of filled viscous Vivadent) and
(Ivoclar composite Variolink II resin
Vivadent) resin (Gaenial, cement (Ivoclar
GC Corp.) Vivadent)
Dietschi Type of Highly filled The use of Yes Full stainless Not specified Not Highly filled CAD/CAM- Not
and adhesive flowable flowable up to steel or clear specified light-curing fabricated applicable
Spreafico system not composites are 1 to 1.5 mm; if matrix and a restorative restorations
[24] specified recommended more material wedge composite made of resin
(Premise Flow, is needed a material (eg, composite
Kerr) or a bulk combination of microhybrid with
fill flowable (eg, flowable and Tetric, Ivoclar; nanoceramic
SureFil SDR restorative or a fillers (Lava
Flow) composite is homogenous Ultimate, 3M
recommended nanohybrid ESPE)
(Inspiro,
EdelweissDR)
Rocca et al. Total-etch Highly filled Limit to the Yes Curved matrix, Fine Sandblasting Light-curing In-lab Not
[25] or 2-step flowable or minimum (1 to full or sectional diamond restorative composite applicable
self-etch hybrid 1.5 mm) needed and a wedge instruments material resin onlays
adhesive composite to bring the (wedge when to remove (Tetric Evo
system preparation possible) the excess Ceram,
supragingivally Ivoclar
(at least 0.5 mm Vivadent)
over the free
gingival
margin)
278 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280
margin (Grade 2) or surgical lengthening of the clinical crown
(Grade 3) is necessary in order to allow for correct isolation of the
operating field. In accordance to these recommendations, the
CMR technique is indeed contraindicated if the cervical prepara-
tion is not perfectly isolated with a rubber dam and a matrix
[10,24,25]. Nevertheless, the case reported by Kielbassa and
Philipp showed a clinical protocol where rubber dam was not
used for relocation of the cervical margin [23]. The isolation with
rubber dam did not prevent bleeding and therefore it was
removed and the isolation was done using cotton rolls, dry-angles
and saliva ejectors under utmost attention to prevent contami-
nation [23].
The use of either circumferential or sectional matrix, either
stainless steel or clear matrix is strongly advocated [3,10,23–25].
Specifically, curved matrices are recommended, as the curvature
allows convergence, adequate emergence profile and a tight
subgingival fit [10,25]. Moreover, reducing the height of the matrix
to 2–3 mm is suggested, so it is slightly higher than the height of
the CMR and in that way the matrix could slide subgingivally and
seal the margin more efficiently [10]. In addition, in cases of
extremely deep and localized subgingival cavities, the final option
could be the matrix-in-a-matrix technique [10].
Regarding the wedging, although it was reported that wedging
is typically not possible [10] or that it is not always possible [25], in
most of the clinical cases presented in the published articles,
matrix in combination with a wooden wedge was anyway applied
[3,23,24].
3.2.3. Treatment of CMR prior to bonding of final restoration
In order to obtain well-defined margins, finishing and polishing
of the restorative material placed at the cervical margin are
required as the last step before impression taking. Elimination of
the excess composite material could be done using a scalpel or a
sickle scaler [10]. Fine diamond rotary instruments are suggested
for removing the excess material, for finishing and polishing, as
well as for obtaining the optimal cavity design [23,25]. Besides,
finishing of the relocated cervical margins was also completed
using flexible discs of decreasing grit and polishing strips [23].
However, the question remains how deeply subgingival interprox-
imal margins could be reached by any of the mentioned materials
and instruments.
Before proceeding with the final impression, Magne and
Spreafico advise a bitewing radiograph to evaluate the adaptation
of the CMR composite resin in the subgingival area and to make
sure that there are no gaps or overhangs [10].
After taking digital or analog impression and fabrication of the
final restoration, different protocols for treatment of the relocated
margin were described. Most of the articles suggest cleaning
the composite by sandblasting, using airborne-particle abrasion
[10,25]. In one case the CMR composite resin was primed
(GC Primer, GC Corp.) prior to adhesive luting of the final
restoration, in order to achieve safe bonding, as reported by the
authors [23].
3.2.4. Follow-up
The clinical case of left second maxillary molar restored with
the CMR and CAD/CAM ceramic inlay presented by Kielbassa and
Philipp [23] was followed up for 3 months. Clinical appearance
showed no signs of inflamed papilla, probing did not reveal
increased probing depth, no bleeding was observed on probing and
no discomfort was reported by the patient.
Long-term clinical view and corresponding radiographs of two
different cases, 9 and 12 years after treatment with CMR and
indirect ceramic restorations, are available in the article by Magne
and Spreafico [10].
4. Discussion
The idea to overcome the difficulties associated with the
placement of restorations in the areas difficult to access by
applying a base that is open to the oral environment underneath,
originates from the “open sandwich technique” in direct composite
Class II restorations. Initially, glass-ionomer cements (GICs) were
proposed as a base material [27] and later, with advancements in
dental material technology, resin-modified GICs [28], polyacid-
modified resin composites [29] and flowable composites [30] were
investigated. Frese et al. [31] described the restoration of
extensively damaged teeth in two clinical steps and called it the
“two-step R2-technique”. In the first step layers of flowable and
viscous composites were applied to relocate the gingival margin
supragingivally and in the second step a direct composite
restoration was placed [31]. Similarly, CMR technique was
proposed as an analog approach to be applied underneath the
indirect adhesive restorations and for that purpose only composite
resin materials were indicated [9].
The in vitro investigations analyzed in this review used
composite materials of various manufacturers, chemical compo-
sitions and viscosities (Table 1). Based on the reported findings, the
overall conclusion could be that the marginal integrity of the
indirect restorations was not significantly influenced by the
application of CMR. Also, the viscosity of the composite resin
was not found to be crucial for the quality of the margins, whereas
the application of composite in several thinner layers could be
considered advisable. Regarding the influence of the restorative
material used for fabrication of final indirect restoration on the
integrity of the relocated cervical margins, no conclusive evidence
could be found.
Nevertheless, the quality of marginal adaptation, as observed
under a microscope, does not necessarily have to correspond to the
quality of the marginal seal of the adhesively bonded composite
material. Inadequate sealing ability may cause leakage of oral fluids
and microorganisms along the tooth/composite interface, which
represents one of the major causes of failure of composite
restorations [32]. Microleakage at the gingival margins of direct
Class II composite restorations [33,34], as well as of indirect
restorations, both ceramic [35] and composite [36], has been well
documented. In addition, application of flowable composite on the
gingival margin as a liner in direct composite restorations did not
reduce microleakage or improve clinical performance of the
restorations [37]. Based on the available evidence, it could be
assumed that applying a layer of composite underneath an indirect
restoration would not prevent leakage. However, no study so far
assessed the leakage at the gingival margins that have been
relocated above CEJ with a composite resin. This would certainly be
worth investigating in order to obtain more relevant information
regarding the in vitro performance of the CMR.
It should also be noticed that in 6 laboratory studies
investigating on the marginal integrity the interfaces that were
examined were not always the same. As a matter of fact, in some of
the studies it was not completely clearly described which of the
margins were evaluated. Besides, the material adaptation to the
enamel margins, judged in some of the studies, could not be
considered essential for assessing the influence of the CMR
technique on the marginal adaptation of indirect restorations. In
the upcoming research more attention should be given to the most
critical margin, the one in dentin, below the CEJ. Different aspects
related to the adhesion of the composite material used for CMR to
dentin and to indirect restorations, as well as to the analysis of the
fracture behavior, the expected fracture pattern and the stress
distribution could be the matter interest of future laboratory
research.
 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280
Moreover, the recent meta-analysis indicates that the survival
rate of ceramic inlays, onlays and overlays remains high (91 %)
after 10 years of follow-up time, regardless of the ceramic
material, study design and study settings [2]. Another literature
review reported 94 % average success for ceramic and composite
indirect restorations, concluding that the low failure rate prove
them to be an excellent choice in treatment of both Class I and II
lesions [1]. Nevertheless, the extent of the cavities below gingival
margins was not included in any of the analysis and no distinction
was made between cavities with proximal cervical margins in
enamel and those in dentin, which could considerably affect the
clinical outcome. The main problem discovered by the present
review is that strong evidence on the clinical performance of
teeth restored with CMR technique and an indirect adhesive
restoration still does not exist. Only several presentations of the
clinical cases could be found (Table 2), which is hardly sufficient
for drawing any conclusions on the potential beneficial or harmful
effects of this technique. Therefore, upcoming clinical research
should focus on important issues related to restoration of Class II
cavities extending below CEJ with indirect adhesive restorations
and, specifically, to the application of CMR technique in such
cases.
One of the possible concerns worth investigating is the
response of the periodontal tissues to the coronally displaced
margins following the CMR technique, as healthy periodontium is a
prerequisite for a successful outcome of any kind of prosthetic or
restorative therapy [38]. Although the margins of the final indirect
restoration would be positioned supragingivally, another restor-
ative margin, the one between the tooth and the composite used
for CMR, remains deep below the gingival margin. This could still
produce detrimental effects, such as gingival inflammation, loss of
periodontal attachment and bone resorption [39]. Therefore, it is
necessary to scientifically prove, through clinical studies, if the
CMR technique could indeed represent the alternative to surgical
crown lengthening or orthodontic extrusion if there is no
compliance with the biological width.
Furthermore, reviewing clinical reports on CMR technique, it
was noticed that there is a lack of consensus on the isolation and
the application technique. According to several studies, CMR
technique should be performed only if the rubber dam, correctly
sheathed in the sulcus, is sufficient to show and isolate the
cervical margin. Nevertheless, in the clinical cases reported in the
literature CMR was also performed without rubber dam isolation.
This should, however, not be a matter of discussion, as placing
CMR composite material in deep subgingival areas without
rubber dam isolation, could seriously threaten the quality of
adhesion, particularly having in mind the fact that adhesion to
dentin is not as strong and durable as adhesion to enamel [11,40].
In addition, the meta-analyses on clinical outcomes of direct Class
II [41] and Class V [42] direct restorations demonstrated that the
use of rubber dam significantly influenced the clinical perfor-
mance and longevity of the restorations. Hence, if it is not
possible to isolate the subgingival margins with a rubber dam, an
important question that arises is whether or not the CMR
technique is indicated.
Finally, after the restoration has been placed and the
periodontal tissues have healed, the patient needs to be able to
adequately maintain the oral hygiene. If the margins between the
tooth and the restoration could not be reached and cleaned in
daily oral hygiene routines, no technique could be considered
appropriate and successful outcome could not be expected.
Therefore, apart from defining more precisely the indication area
and strict clinical protocol, future well-designed randomized
controlled clinical trials should concentrate on verifying the
claimed advantageous features of CMR technique on the long-
279
term clinical outcome of teeth restored with indirect adhesive
restorations.
5. Conclusions
On the basis of the reviewed literature, it can be concluded that
currently there is no strong scientific evidence that could either
support or discourage the use of CMR technique prior to
restoration of deep subgingival defects with indirect adhesive
restorations. Randomized controlled clinical trials are necessary to
provide the reliable evidence on the influence of CMR technique on
the clinical performance, especially on the longevity of the
restorations and the periodontal health.
References
[1] Mangani F, Marini S, Barabanti N, Preti A, Cerutti A. The success of indirect
restorations in posterior teeth: a systematic review of the literature. Minerva
Stomatol 2015;64:231–40.
[2] Morimoto S, Rebello de Sampaio FB, Braga MM, Sesma N, Ozcan M. Survival
rate of resin and ceramic inlays, onlays, and overlays: a systematic review and
meta-analysis. J Dent Res 2016;95:985–94.
[3] Veneziani M. Adhesive restorations in the posterior area with subgingival
cervical margins: new classification and differentiated treatment approach.
Eur J Esthet Dent 2010;5:50–76.
[4] Ingber JS, Rose LF, Coslet JG. The “biologic width”—a concept in periodontics
and restorative dentistry. Alpha Omegan 1977;70:62–5.
[5] Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical crown
lengthening: evaluation of the biological width. J Periodontol 2003;74:
468–74.
[6] Felippe LA, Monteiro Júnior S, Vieira LC, Araujo E. Reestablishing biologic
width with forced eruption. Quintessence Int 2003;34:733–8.
[7] D’Arcangelo C, Vanini L, Casinelli M, Frascaria M, De Angelis F, Vadini M, et al.
Adhesive cementation of indirect composite inlays and onlays: a literature
review. Compend Contin Educ Dent 2015;36:570–7 quiz 8.
[8] Keys W, Carson SJ. Rubber dam may increase the survival time of dental
restorations. Evid Based Dent 2017;18:19–20.
[9] Dietschi D, Spreafico R. Current clinical concepts for adhesive cementation of
tooth-colored posterior restorations. Pract Periodontics Aesthet Dent
1998;10:47–54 quiz 56.
[10] Magne P, Spreafico R. Deep margin elevation: a paradigm shift. Am J Esthet
Dent 2012;2:86–96.
[11] Cardoso MV, de Almeida Neves A, Mine A, Coutinho E, Van Landuyt K, De
Munck J, et al. Current aspects on bonding effectiveness and stability in
adhesive dentistry. Aust Dent J 2011;56(Suppl. 1):31–44.
[12] Perdigao J. Dentin bonding as a function of dentin structure. Dent Clin North
Am 2002;46:277–301 vi.
[13] Kugel G, Ferrari M. The science of bonding: from first to sixth generation. J Am
Dent Assoc 2000;131(Suppl):20S–5S.
[14] Van Meerbeek B, Van Landuyt K, De Munck J, Hashimoto M, Peumans M,
Lambrechts P, et al. Technique-sensitivity of contemporary adhesives. Dent
Mater J 2005;24:1–13.
[15] Roggendorf MJ, Kramer N, Dippold C, Vosen VE, Naumann M, Jablonski-
Momeni A, et al. Effect of proximal box elevation with resin composite
on marginal quality of resin composite inlays in vitro. J Dent 2012;40:
1068–73.
[16] Frankenberger R, Hehn J, Hajto J, Kramer N, Naumann M, Koch A, et al. Effect of
proximal box elevation with resin composite on marginal quality of ceramic
inlays in vitro. Clin Oral Investig 2013;17:177–83.
[17] Zaruba M, Gohring TN, Wegehaupt FJ, Attin T. Influence of a proximal margin
elevation technique on marginal adaptation of ceramic inlays. Acta Odontol
Scand 2013;71:317–24.
[18] Ilgenstein I, Zitzmann NU, Buhler J, Wegehaupt FJ, Attin T, Weiger R, et al.
Influence of proximal box elevation on the marginal quality and fracture
behavior of root-filled molars restored with CAD/CAM ceramic or composite
onlays. Clin Oral Investig 2015;19:1021–8.
[19] Spreafico R, Marchesi G, Turco G, Frassetto A, Di Lenarda R, Mazzoni A, et al.
Evaluation of the in vitro effects of cervical marginal relocation using
composite resins on the marginal quality of CAD/CAM crowns. J Adhes Dent
2016;18:355–62.
[20] Da Silva Goncalves D, Cura M, Ceballos L, Fuentes MV. Influence of proximal
box elevation on bond strength of composite inlays. Clin Oral Investig
2017;21:247–54.
[21] Müller V, Friedl KH, Friedl K, Hahnel S, Handel G, Lang R. Influence of proximal
box elevation technique on marginal integrity of adhesively luted Cerec inlays.
Clin Oral Investig 2017;21:607–12.
[22] Frankenberger R, Lohbauer U, Schaible RB, Nikolaenko SA, Naumann M. Luting
of ceramic inlays in vitro: marginal quality of self-etch and etch-and-rinse
adhesives versus self-etch cements. Dent Mater 2008;24:185–91.
280 J. Juloski et al. / journal of prosthodontic research 62 (2018) 273–280
[23] Kielbassa AM, Philipp F. Restoring proximal cavities of molars using the
proximal box elevation technique: systematic review and report of a case.
Quintessence Int 2015;46:751–64.
[24] Dietschi D, Spreafico R. Evidence-based concepts and procedures for bonded
inlays and onlays. Part I. Historical perspectives and clinical rationale for a
biosubstitutive approach. Int J Esthet Dent 2015;10:210–27.
[25] Rocca GT, Rizcalla N, Krejci I, Dietschi D. Evidence-based concepts and
procedures for bonded inlays and onlays. Part II. Guidelines for cavity
preparation and restoration fabrication. Int J Esthet Dent 2015;10:
392–413.
[26] Magne P, Nielsen B. Interactions between impression materials and immediate
dentin sealing. J Prosthet Dent 2009;102:298–305.
[27] Welbury RR, Murray JJ. A clinical trial of the glass-ionomer cement-composite
resin “sandwich” technique in class II cavities in permanent premolar and
molar teeth. Quintessence Int 1990;21:507–12.
[28] van Dijken JW, Kieri C, Carlen M. Longevity of extensive class II open-sandwich
restorations with a resin-modified glass-ionomer cement. J Dent Res
1999;78:1319–25.
[29] Lindberg A, van Dijken JW, Lindberg M. Nine-year evaluation of a polyacid-
modified resin composite/resin composite open sandwich technique in class II
cavities. J Dent 2007;35:124–9.
[30] Fabianelli A, Sgarra A, Goracci C, Cantoro A, Pollington S, Ferrari M.
Microleakage in class II restorations: open vs closed centripetal build-up
technique. Oper Dent 2010;35:308–13.
[31] Frese C, Wolff D, Staehle HJ. Proximal box elevation with resin composite and
the dogma of biological width: clinical R2-technique and critical review. Oper
Dent 2014;39:22–31.
[32] Pashley DH. Clinical considerations of microleakage. J Endod 1990;16:70–7.
[33] Rengo C, Goracci C, Juloski J, Chieffi N, Giovannetti A, Vichi A, et al. Influence of
phosphoric acid etching on microleakage of a self-etch adhesive and a self-
adhering composite. Aust Dent J 2012;57:220–6.
[34] Juloski J, Carrabba M, Aragoneses JM, Forner L, Vichi A, Ferrari M. Microleakage
of class II restorations and microtensile bond strength to dentin of low-
shrinkage composites. Am J Dent 2013;26:271–7.
[35] Uludag B, Ozturk O, Ozturk AN. Microleakage of ceramic inlays luted with
different resin cements and dentin adhesives. J Prosthet Dent 2009;102:235–41.
[36] Gerdolle DA, Mortier E, Loos-Ayav C, Jacquot B, Panighi MM. In vitro evaluation
of microleakage of indirect composite inlays cemented with four luting agents.
J Prosthet Dent 2005;93:563–70.
[37] Boruziniat A, Gharaee S, Sarraf Shirazi A, Majidinia S, Vatanpour M. Evaluation
of the efficacy of flowable composite as lining material on microleakage of
composite resin restorations: a systematic review and meta-analysis.
Quintessence Int 2016;47:93–101.
[38] Padbury Jr. A, Eber R, Wang HL. Interactions between the gingiva and the
margin of restorations. J Clin Periodontol 2003;30:379–85.
[39] Schatzle M, Land NP, Anerud A, Boysen H, Burgin W, Loe H. The influence of
margins of restorations of the periodontal tissues over 26 years. J Clin
Periodontol 2001;28:57–64.
[40] Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo
E. Dental adhesion review: aging and stability of the bonded interface. Dent
Mater 2008;24:90–101.
[41] Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations — a
meta-analysis. J Adhes Dent 2012;14:407–31.
[42] Mahn E, Rousson V, Heintze S. Meta-analysis of the influence of bonding
parameters on the clinical outcome of tooth-colored cervical restorations. J
Adhes Dent 2015;17:391–403.